HESI RN
HESI RN Exit Exam 2024 Capstone
1. During an acute exacerbation of asthma, what is the nurse's first action for a client experiencing this condition?
- A. Administer a bronchodilator as prescribed.
- B. Check the client's oxygen saturation.
- C. Reassure the client and encourage deep breathing.
- D. Provide emotional support to reduce anxiety.
Correct answer: A
Rationale: The correct first action when managing an acute exacerbation of asthma is to administer a bronchodilator as prescribed. Bronchodilators help open the airways and improve breathing in individuals experiencing an asthma exacerbation. Checking oxygen saturation (Choice B) is important but not the first action. Reassuring the client and encouraging deep breathing (Choice C) can be beneficial but should come after administering the bronchodilator. Providing emotional support to reduce anxiety (Choice D) is important but is not the initial priority in managing an acute exacerbation of asthma.
2. A client with tuberculosis (TB) is being discharged on isoniazid and rifampin. What instruction should the nurse prioritize?
- A. Complete the full course of antibiotics.
- B. Notify the healthcare provider if you experience tingling in your fingers.
- C. Use a disposable mask when in contact with others.
- D. Monitor liver function tests monthly.
Correct answer: C
Rationale: The correct answer is to instruct the client to use a disposable mask when in contact with others. TB is highly contagious, and wearing a mask can help prevent the spread of the disease to others. Choice A is important but not the priority as using a mask directly impacts public health. Choice B is related to a potential side effect of isoniazid, peripheral neuropathy, but immediate healthcare provider notification is not required. Choice D is relevant due to the potential hepatotoxicity of isoniazid and rifampin, but it is not the priority instruction in this scenario.
3. A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?
- A. Crush the medications and mix them with applesauce.
- B. Encourage the client to drink water with each dose.
- C. Consult with the healthcare provider about switching to liquid medications.
- D. Offer the client soft foods to reduce difficulty swallowing.
Correct answer: C
Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.
4. A client with a ruptured spleen underwent an emergency splenectomy. Twelve hours later, the client’s urine output is 25 ml/hour. What is the most likely cause?
- A. This is a normal finding after surgery.
- B. Oliguria signals tubular necrosis related to hypoperfusion.
- C. Oliguria signals dehydration and fluid loss.
- D. Urine output of 25 ml/hour is an expected finding after splenectomy.
Correct answer: B
Rationale: Oliguria, or decreased urine output, after surgery can indicate tubular necrosis due to hypoperfusion, which may require intervention to restore renal function. Choice A is incorrect as oliguria is not a normal finding after surgery. Choice C is incorrect because dehydration is less likely in this context compared to tubular necrosis. Choice D is incorrect as a urine output of 25 ml/hour is not expected after splenectomy and should raise concern for renal impairment.
5. The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?
- A. Increase fluid intake with meals
- B. Avoid lying down for at least 30 minutes after eating
- C. Eat small, frequent meals throughout the day
- D. Consume spicy foods in moderation
Correct answer: C
Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.
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